In current radiology, images are created by an operator of medical imaging equipment in response to a request. In response to this request, images are made and subsequently, a report is created. The request typically describes a modality and an area in the body, and can be extended with a description of complaints or a possible diagnosis to be confirmed or excluded. In most cases the images are created by technologists, and the report is later made in a reading room by the radiologist. In some cases (for example, in case of ultrasound studies) the radiologist may perform the imaging himself.
Subsequently, the report is created. The common way to do this is by dictation, where either speech recognition or transcription is used to create a written report. The content of this report may be formalized to some extent. However, the resulting text is not structured.
Recently, a trend has appeared towards structured reporting. Herein, the report is structured so that other applications can make use of the information contained within. A recent initiative by RSNA is to publish a set of templates for the structure of the reports for a number of different applications.
An advanced area for reporting is breast cancer diagnosis, where the ACR's Breast Imaging Reporting and Data System (BI-RADS) describes the wording and structure of the report for the three modalities Mammography (X-Ray), Ultrasound, and MRI. Parts of BI-RADS have been incorporated into the DICOM Structured Reporting for Mammography CAD SOP Class definition. Analysis packages like DynaCAD (Invivo), CADStream (Merge), and B-CAD (Medipattern) use a dedicated user interface to fill in a BI-RADS form and link the reported findings to key images. Philips IntelliSpace Breast is capable of doing the same, for all modalities. It encodes the content in a DICOM Structured Report.
In Ultrasound, DICOM structured Reports are used to store reports generated on the cart, for instance in cardiology. However, all these user interfaces are specific to the area of application.